Case VII SA/Wa 185/07

On August 2006, the Director of the Voivodeship Branch of the National Health Fund rejected the application of the plaintiffs for the reimbursement of the costs incurred during the plaintiff’s in vitro fertilization procedure. The plaintiffs had neither obtained a physician’s referral for the in vitro treatment nor filed an application with the Director of the Voivodeship Branch of the National Health Fund requesting a confirmation of their right to the procedure prior to undertaking treatment.  This decision was upheld on appeal by the President of the National Health Fund.

The plaintiffs filed a complaint against this decision, arguing that the Article 68, Section 2 of the Polish Constitution guaranteed to all citizens equal access to publicly funded healthcare benefits on the conditions and to the extent specified in the relevant statute, which included fertility treatments.

The Court stated that recipients of healthcare benefits were entitled to healthcare benefits, including fertility treatments, on the basis of a referral issued by a health insurance physician, pursuant to the Article 32 of the Act of 27 August 2004 on Publicly Funded Healthcare Benefits.  Thus, the Court held that a referral was a necessary condition for an insured person to obtain financing for diagnostic examinations from public funds. Moreover, the Court noted that the financing of healthcare benefits under the Act excluded direct payments to the healthcare recipients, but rather only entitled the provider of healthcare benefits to renumeration.

Thus, the Court determined that as the plaintiffs did not have a proper referral from a health insurance physician they were not entitled to reimbursement for their costs. The Court held that the decision by the National Health Fund did not violate the law, and dismissed the complaint by the plaintiffs.

“ All recipients of healthcare benefits are entitled to healthcare benefits regarding diagnostic examinations qualified as guaranteed benefits on the basis of a referral issued by a health insurance physician (Art. 32 of the Act)..Thus, a referral is a necessary condition for the emergence of right of the insured person to the financing of diagnostic examinations from public funds, while the entities bound to finance these and other benefits on the conditions and to the extent specified in the Act are the competent ministers or the Fund (Art. 14 of the Act on Benefits).”) Page 3.

“Prawo do świadczeń z zakresu badań diagnostycznych, zakwalifkowanych jako świadczenia gwarantowane, ma każdy świadczeniobiorca na podstawie skierowania lekarza ubezpieczenia społecznego (art. 32 ustawy). Skierowanie jest zatem warunkiem koniecznym do powstania prawa ubezpieczonego do sfinansowania badań ze środków publicznych, przy czym podmiotami zobowiązanymi do finansowania m.in. tych świadczeń na zasadach I w zakresie określonym w ustawie są właściw iministrowie lub Fundusz - art. 14 ustawy o świadczeniach.” Page 3.

“At the time of commencement of the diagnostic examinations and of the procedure of extracorporeal fertilization, the complainants did not have a referral from a health insurance physician to conduct examinations qualified as guaranteed benefits. As indicated hereinabove, such referral is a necessary condition for the emergence of the right of an insured person to finance examinations from public funds” Page 3

“Skarżący przystępując do badań diagnostycznych i procedury zapłodnienia pozaustrojowego nie posiadali skierowania od lekarza ubezpieczenia społecznego do wykonania badań, zakwalifikowanych jako świadczenia gwarantowane. Skierowanie takie, jak już wskazano, jest warunkiem koniecznym do powstania prawa ubezpieczonego do sfinansowania badań ze środków publicznych.” Page 3